North Minneapolis is one of the Minnesota city’s most diverse neighborhoods, and one of its poorest. Devastated by riots in the late 1960s, the neighborhood has the highest crime rate in Minneapolis and limited public transportation options.

According to the federal government, the neighborhood is also a food desert. Researchers have used the term for decades to describe areas of the country—often poor or remote—where healthy food choices are hard to find.

North Minneapolis is a prime example. It has just one small grocery store, and almost half of the area’s residents are dependent on public transportation, limiting their shopping options. And, says resident DeVon Nolen, “we have a high concentration of [people with] diabetes in the area.”

But the problem is more complicated than it seems on the surface. Nolen, who manages a weekly farmers market in the middle of North Minneapolis, likes to point out that people in her area don’t have trouble finding something to eat. She recently counted 37 restaurants on a 2.2-mile stretch of road that runs through the neighborhood. The problem is, they serve hamburgers, fried chicken, and pizza. Her neighbors often rely on drugstores and corner markets for meals.

The trouble people in North Minneapolis have when it comes to accessing healthy food reflects a larger problem in America: food insecurity. The U.S. Department of Agriculture (USDA) defines it as “a lack of consistent access to enough food for an active, healthy life,” and it’s an issue that touches people of all ages with all types of diabetes.

The USDA estimates that 40 million Americans—including 12 million children—experienced food insecurity in 2017. That means that an estimated 1 in 10 households couldn’t access or afford “enough food for an active, healthy life for all household members.”

Likely Companions

Whether it’s the result of too many empty calories (found in junk food such as potato chips and candy bars) or not enough nutritious ones, research shows that food insecurity in all its forms is a major risk factor for type 2 diabetes. In a study published in 2018 in the journal PLOS One, University of Toronto public health expert Christopher Tait, PhD, looked at health records and survey data from thousands of people living in the Canadian province of Ontario. The data showed a strong connection between food insecurity and diabetes. People who reported living in food-insecure households, Tait found, “were more than twice as likely to develop type 2 diabetes as those in food-secure households.”

The findings might not make sense at first glance. After all, type 2 diabetes is often portrayed as a disease of excess: Too much food leads to obesity and eventually diabetes. Poverty, meanwhile, is connected with scarcity, including not having enough to eat.

But the reality is sometimes the opposite. “The experience of food insecurity in the U.S. is somewhat unique,” says Andrea Warren, PhD, a researcher at the University of South Carolina. For most Americans experiencing food insecurity, the problem isn’t that they’re getting too few calories; it’s that they’re getting too many of the wrong kind.

“The food [that’s easiest] to access tends to be high calorie,” says Tait, noting that people who are food insecure “may be getting enough calories, but the calories they are getting contribute to weight gain.”

In other words: The cheapest and most readily available foods—fatty, fried takeout, high-sodium prepared meals, candy, and soft drinks—provide plenty of calories, but they contribute to or make it hard to properly manage chronic conditions such as high blood pressure, kidney disease, and diabetes. “You can meet your caloric daily requirement with pasta,” Warren says, “but that doesn’t mean it’s a healthy diet.”

That’s why researchers and food policy experts have begun moving away from the term food desert. “It’s not clear a food desert in itself is enough to create weight increase or an unhealthy diet,” says medical anthropologist Joel Gittelsohn, PhD, a professor in the Department of International Health at Johns Hopkins University Bloomberg School of Public Health. “Neighborhoods that lack supermarkets may still have a lot of places where residents can buy food, for example. It’s just not very good food.”

Instead of barren deserts, Gittelsohn says it’s more accurate to think of such neighborhoods as swamps. “The term food desert is misleading because calling something a desert implies there’s no food,” he says. “Like a swamp, poor neighborhoods may be flooded with stores and fast-food restaurants peddling unhealthy foods and sugary soda.”

Diabetes may be tied to food insecurity in other ways, too. For some people, diabetes may be the cause of their food insecurity, not just the result, says Enza Gucciardi, PhD, a nutrition researcher at Ryerson University in Toronto, Canada. Someone with complications from diabetes may have a harder time holding down a job, for example. And people on limited budgets might have to make hard choices between meals and medication to manage their diabetes. “If you have diabetes, or if you have a family and a child with diabetes, there are higher expenses,” Gucciardi says.

For adults and children who already have type 1 or type 2 diabetes, food insecurity can also increase the risk of complications. “If you start skipping meals, it plays havoc on your blood sugar levels and puts you at higher risk of hypoglycemia,” says Gucciardi. A study published in 2011 in the Archives of Internal Medicine found that food-insecure people with diabetes experienced twice as many hypoglycemic episodes as food-secure people with diabetes. On the flip side, those with diabetes who can afford only unhealthy fare may have more frequent high blood glucose levels, which can raise the risk oflong-term complications.

Eliminating food insecurity would go a long way toward reducing the burden of diabetes. “Thinking about how to increase the accessibility and affordability of healthy food could make a big difference,” Tait says. But researchers are quick to point out that food insecurity, like poverty, won’t be an easy problem to fix.

Improving Access

A handful of cities around the country are taking steps to change the situation. In 2008, Minneapolis passed a first-of-its-kind law called the Staple Foods Ordinance. The law requires stores that sell food to stock produce and basic staples. The measure affected not just supermarkets, but also hundreds of corner stores, pharmacies, gas stations, and convenience stores across the city. You can now find fresh fruits and vegetables, milk, eggs, and products made with whole grains in addition to energy drinks, potato chips, and candy bars.

The city’s health department has worked with stores to help them implement the law, and Melissa Laska, PhD, RD, a professor of epidemiology and community health at the University of Minnesota School of Public Health, says things are improving—slowly.

But the challenges remain huge. “I see stores trying,” she says. “They put a basket of bananas on the counter as a healthier impulse buy. But then there’s eight feet of counter space covered with candy, a Red Bull cooler next to the register, and a wall of cigarettes behind the counter,” Laska says. “It’s difficult to be a customer in some of these stores and still make healthy choices.”

That doesn’t mean change is impossible. Community leaders such as Nolen are working to find local solutions. Eight years ago, she helped start the West Broadway Farmers Market, located on the main street running through North Minneapolis. Once a week between mid-June and early October, people in the area have easy access to fresh fruits and vegetables brought in from local farms. An event that started with Nolen flagging people down as they drove past has grown into a neighborhood fixture with 12,000 customers in 2018. Nolen says it’s one of the few thriving urban farmers markets in the Minneapolis area.

A few years ago, the farmers market partnered with a local doctor to offer people with diabetes “prescriptions” for fruits and vegetables. The prescriptions are worth up to $20 a week in produce at the farmers market, funded through grants from the USDA and North Point Health and Wellness, a local health care provider. “We’re educating patients to use food as medicine,” she says. “It’s really inexpensive, when you think about the deeper health implications.”

The “food prescriptions” have been a big success. Participants report eating healthier and come back week after week to shop. “If we can change the conditions around food,” says Nolen, “we can change food-related conditions.”

Going Hungry

The focus on food insecurity in inner cities has expanded to recognize that there are other groups that may have a hard time accessing healthy food. People in small towns and rural areas, for example, can face long drives to supermarkets with limited stock.

Older adults are another group that is particularly vulnerable to food insecurity and diabetes alike. Working with Feeding America, a national network of over 200 food banks, University of South Carolina public health researcher Andrea Warren, PhD, talked to food bank staffers and their older clients in nine states.

She found that diabetes was a major concern among older adults who depended on food banks. “Diabetes management was a real challenge for them,” Warren says. “The No. 1 thing they reported was that they couldn’t afford the right foods to manage their diabetes.”

Warren’s research revealed that programs designed to address food insecurity often fail older people with diabetes. Food banks, she says, are frequently designed around getting high-calorie staple foods such as pasta and bread to as many people in need as possible.

Meanwhile, fresh produce and proteins aren’t available to older adults on a tight budget or to those with mobility issues. Food boxes, for example, are often full of carbs. Her research found that juice, pasta, and white rice were standard.

Accessing the right types of food wasn’t the only issue. Preparing food from scratch was equally tough. “A lot of seniors, for various reasons, are unable to cook complicated things,” Warren says. “They’re unable to stand, or arthritis makes chopping hard.” Older adults said they depended on sandwiches, canned soups, or meals they could microwave.

Warren says it’s important to think harder about ways to help older adults stay healthy. “When you’re looking at food assistance, it’s not designed to be responsive to the needs of people with diabetes,” she says.

Warren’s research highlighted some model programs that tried to tackle the needs of older adults with diabetes. One South Carolina food bank worked with Meals on Wheels to deliver low-sodium, diabetes-appropriate prepared meals to homebound seniors. And a California program packed diabetes-specific commodity food boxes with whole grains, quinoa, and protein-rich beans for its older clients with diabetes and high blood pressure.

As the population ages—by 2035, there will be more people in the United States over 65 than under 18—older adults, and older adults with diabetes, will represent a larger proportion of the food insecure. “We need to not just provide meals, but provide meals that ward off these health outcomes,” Warren says.

That’s not to say hunger can’t still play a role. University of Toronto public health expert Christopher Tait, PhD, says many people who rely on public assistance for all or part of their food budgets may not be able to stretch their money to last until their next assistance payment.

That means people go through cycles where they eat a lot, followed by days of hunger. “Binge-fast cycles—overconsumption followed by chronic underconsumption—may add to the risk of insulin resistance,” Tait says. The cycle can strain the body’s capacity to produce insulin and eventually lead to type 2 diabetes.

If you’re struggling to eat properly on a limited budget, or for other reasons, there are resources that can help:

Food Assistance

Your community may have a food bank program or food pantry. Or you may qualify for the Supplemental Nutrition Assistance Program (SNAP), a U.S. Department of Agriculture program that provides food aid to those in need.

Diabetes Care

Talk to your doctor or diabetes educator about your situation. They may be able to prescribe lower-cost insulin or refer you to programs designed to help with prescription costs.

To push for solutions to food insecurity in your area, consider:

Advocating for summer farmers markets to provide an indoor winter market as well

Looking for local programs that cultivate inner-city gardening spots, or school gardening programs that teach kids about healthy food choices

Pushing for free breakfasts at schools

Supporting laws and programs that repurpose foods left over from local restaurants, bakeries, and grocery stores